Georgia Medicare Cardiac Rehabilitation and Intensive Cardiac Rehab Benefits

::: hero

By Brevy Care Team · Last verified May 13, 2026

Cardiac rehabilitation is one of the highest-impact and most consistently underutilized Medicare benefits. The scientific evidence is unambiguous: for beneficiaries who have had a qualifying cardiac event (acute myocardial infarction, coronary artery bypass graft surgery, stable angina, heart valve repair or replacement, percutaneous coronary intervention, heart transplant, or stable chronic heart failure with LVEF at or below 35 percent), participation in a structured cardiac rehabilitation program reduces all-cause mortality by 13 to 26 percent, reduces cardiovascular mortality by 26 to 36 percent, reduces hospital readmissions, improves exercise capacity, improves quality of life, and improves medication adherence. Yet only about 30 percent of eligible Medicare beneficiaries actually participate, and Georgia's participation rates trail the national average in many regions.

This guide explains the federal statutory architecture of Medicare's cardiac rehabilitation benefit under Section 1861(eee) of the Social Security Act, the seven qualifying conditions that establish eligibility, the structure of traditional cardiac rehabilitation (CR) versus intensive cardiac rehabilitation (ICR), the CMS-approved ICR programs (Pritikin, Dr. Dean Ornish Program for Reversing Heart Disease, and Benson-Henry Institute Cardiac Wellness Program), the 2014 National Coverage Determination expansion that added stable chronic heart failure to the qualifying conditions, the 2019 Bipartisan Budget Act 2018 expansion of supervision authority to physician assistants and nurse practitioners, the 2024 Consolidated Appropriations Act expansion of the ICR program approval pathway, and how Georgia beneficiaries access cardiac rehabilitation services across the major Georgia health systems (Emory, Piedmont, Wellstar, Northeast Georgia Health System, Memorial Health, AU Medical Center, Atrium Health Navicent, Phoebe Putney, Grady) and the limited but valuable Pritikin and Ornish ICR sites available in the state. We will work through six detailed case examples and fourteen common mistakes that keep Georgia families from getting the cardiac rehab care they qualify for. :::

::: callout Key Takeaways

1. Medicare cardiac rehabilitation services are covered under Section 1861(eee) of the Social Security Act and the implementing regulation at 42 CFR 410.49. The benefit was established by Section 144 of the Medicare Improvements and Extension Act of 2006 (Division B of the Tax Relief and Health Care Act, Public Law 109-432) and has been refined by ACA 2010, BBA 2018, and CAA 2024.

2. Seven qualifying conditions establish eligibility under 42 CFR 410.49(b)(1): acute myocardial infarction within the preceding 12 months, coronary artery bypass graft (CABG) surgery, current stable angina pectoris, heart valve repair or replacement, percutaneous coronary intervention (PCI) including stent, heart or heart-lung transplant, and stable chronic heart failure with LVEF at or below 35 percent and NYHA class II through IV symptoms despite at least 6 weeks of optimal medical therapy (added by National Coverage Determination 20.10.1 in 2014).

3. Traditional cardiac rehabilitation (CR) provides up to 36 one-hour sessions over 36 weeks (typically 3 sessions per week for 12 weeks), with the possibility of extension to 72 sessions when medically necessary and documented by the physician. CR is paid under the Outpatient Prospective Payment System (OPPS) at APC 5771 (Level 1) or APC 5772 (Level 2), with beneficiary coinsurance of 20 percent of the Medicare-approved amount after the Part B deductible.

4. Intensive cardiac rehabilitation (ICR) under Section 1861(eee)(4) provides up to 72 one-hour sessions over 18 weeks, paid at a higher OPPS rate than traditional CR. ICR is delivered through CMS-approved programs that meet specific evidence-based intensity requirements. Three programs are currently approved: the Pritikin Program, the Dr. Dean Ornish Program for Reversing Heart Disease, and the Benson-Henry Institute Cardiac Wellness Program.

5. Section 51008 of the Bipartisan Budget Act of 2018 (Public Law 115-123), effective January 1, 2019, expanded supervision authority for cardiac rehabilitation to allow physician assistants (PAs), nurse practitioners (NPs), and clinical nurse specialists (CNSs) to supervise CR and pulmonary rehabilitation in addition to physicians. This expansion improved access in rural and underserved areas of Georgia.

6. Section 4117 of the Consolidated Appropriations Act 2024 expanded the pathway for CMS approval of additional ICR programs, creating clearer criteria for evidence-based programs to seek approval.

7. Cardiac rehabilitation programs include four required components under 42 CFR 410.49(c): physician-prescribed exercise each day cardiac rehab is furnished, cardiac risk factor modification including education and counseling and behavioral intervention, psychosocial assessment, and outcomes assessment. The individualized treatment plan must be reviewed by a physician every 30 days.

8. Georgia beneficiaries access cardiac rehabilitation through major health systems including Emory Healthcare, Piedmont Healthcare, Wellstar Health System, Northeast Georgia Health System, Memorial Health, AU Medical Center, Atrium Health Navicent, Phoebe Putney Health System, and Grady Health System. The Pritikin Intensive Cardiac Rehabilitation Program at Memorial Health University Medical Center in Savannah has been a notable ICR site in the state. :::

Federal Statutory and Regulatory Framework

Section 1861(eee): The Cardiac Rehabilitation Statutory Authority

Section 1861(eee) of the Social Security Act is the foundational statutory authority for Medicare's cardiac rehabilitation benefit. Added by Section 144 of the Medicare Improvements and Extension Act of 2006 (Division B of the Tax Relief and Health Care Act, Public Law 109-432), Section 1861(eee) defines cardiac rehabilitation services and intensive cardiac rehabilitation services as covered Medicare services. The statutory structure has four key subsections:

1. Section 1861(eee)(1) defines cardiac rehabilitation as a physician-supervised program that furnishes physician-prescribed exercise, cardiac risk factor modification (including education, counseling, and behavioral intervention), psychosocial assessment, and outcomes assessment.

2. Section 1861(eee)(2) establishes program requirements including the qualifying medical conditions, the requirement for an individualized treatment plan, the physician oversight requirement, and the documentation requirements.

3. Section 1861(eee)(3) specifies the qualifying conditions for the benefit (further detailed in the implementing regulation).

4. Section 1861(eee)(4) establishes intensive cardiac rehabilitation as a distinct category for CMS-approved programs that demonstrate evidence-based intensity and superior outcomes.

The 2006 enactment of Section 1861(eee) consolidated and clarified what had been a patchwork of coverage policies for cardiac rehabilitation that varied by Medicare Administrative Contractor and that often used local coverage determinations to define the scope of the benefit. The statutory codification gave the benefit a clear national footprint and a defined set of qualifying conditions.

42 CFR 410.49: Conditions of Coverage for Cardiac Rehabilitation

The implementing regulation at 42 CFR 410.49 spells out the detailed conditions of coverage. The key elements are:

Qualifying Conditions (42 CFR 410.49(b)(1))

To qualify for cardiac rehabilitation under Medicare Part B, the beneficiary must have one of the following conditions:

1. Acute myocardial infarction within the preceding 12 months. The AMI may have been a STEMI (ST-elevation MI) or NSTEMI (non-ST-elevation MI). The 12-month window starts from the date of the AMI.

2. Coronary artery bypass graft (CABG) surgery. The CABG may have been single-vessel, multivessel, on-pump, off-pump, with or without concurrent valve surgery.

3. Current stable angina pectoris. Stable angina is defined as anginal chest pain that has been stable in frequency, duration, and provoking factors. Unstable angina is not a qualifying condition for outpatient cardiac rehab (though the beneficiary becomes eligible after stabilization).

4. Heart valve repair or replacement. Includes aortic valve replacement (surgical SAVR or transcatheter TAVR), mitral valve repair or replacement, tricuspid valve repair or replacement, and pulmonic valve interventions.

5. Percutaneous coronary intervention (PCI) including coronary stenting. PCI includes balloon angioplasty, bare-metal stenting, and drug-eluting stenting. Both elective PCI and emergency PCI for AMI qualify.

6. Heart or heart-lung transplant. Transplant recipients qualify for cardiac rehab as part of their post-transplant recovery and rehabilitation.

7. Stable, chronic heart failure with LVEF at or below 35 percent and NYHA class II through IV symptoms despite at least 6 weeks of optimal medical therapy. This qualifying condition was added by National Coverage Determination 20.10.1 in February 2014. Before 2014, heart failure was not a qualifying condition despite robust evidence that heart failure patients benefit substantially from cardiac rehabilitation.

Components of Cardiac Rehab (42 CFR 410.49(c))

A qualifying cardiac rehabilitation program must include four components:

1. Physician-prescribed exercise each day cardiac rehab items and services are furnished. Exercise prescription is individualized based on the beneficiary's medical condition, exercise tolerance, and goals.

2. Cardiac risk factor modification including education, counseling, and behavioral intervention. Risk factor modification addresses smoking cessation, dietary modification, weight management, lipid control, blood pressure control, glycemic control in diabetic patients, and physical activity beyond the structured program.

3. Psychosocial assessment. Assessment of depression, anxiety, social support, and other psychosocial factors that affect cardiac outcomes.

4. Outcomes assessment. Documentation of changes in exercise capacity, risk factor profile, and quality of life.

The individualized treatment plan must be reviewed by a physician every 30 days.

Setting (42 CFR 410.49(d))

CR services may be furnished in a hospital outpatient department or a physician's office. CR delivered in a hospital outpatient department is paid under OPPS. CR delivered in a physician's office is paid under the Medicare Physician Fee Schedule (MPFS) with a different payment structure.

Frequency and Duration (42 CFR 410.49(g))

• Traditional CR: Up to 2 sessions per day, up to 36 sessions over 36 weeks. Up to 72 sessions may be approved when medically necessary and documented.
• Intensive CR: Up to 6 sessions per day, up to 72 sessions over 18 weeks.

Supervision (42 CFR 410.49(b)(2))

Direct supervision is required. Direct supervision means the supervising clinician is in the office suite and immediately available to furnish assistance and direction during the procedure. The supervising clinician does not have to be present in the room. As of January 1, 2019, under Section 51008 of the Bipartisan Budget Act of 2018, physician assistants, nurse practitioners, and clinical nurse specialists may supervise cardiac rehab (in addition to physicians).

NCD 20.10 and NCD 20.10.1

National Coverage Determination (NCD) 20.10 originally addressed cardiac rehabilitation coverage. The NCD has been updated multiple times to refine coverage criteria and to align with the statutory framework.

NCD 20.10.1, issued by CMS in February 2014, expanded the qualifying conditions to include stable chronic heart failure with LVEF at or below 35 percent and NYHA class II through IV symptoms despite at least 6 weeks of optimal medical therapy. This was a major expansion of access. The clinical evidence base for cardiac rehabilitation in heart failure patients had been building for years through trials including HF-ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training), which demonstrated that exercise training in stable heart failure patients improved exercise capacity, reduced hospitalizations, and improved quality of life with acceptable safety. CMS issued NCD 20.10.1 to align Medicare coverage with the evidence base.

For Georgia, the 2014 heart failure expansion meant that beneficiaries with HFrEF (heart failure with reduced ejection fraction) who would have been excluded from CR before 2014 now had access to a major secondary prevention intervention. Heart failure affects roughly 6 million Americans, including a disproportionate number of older adults, and Georgia has one of the highest heart failure prevalence rates in the country due to its high rates of hypertension, diabetes, obesity, and coronary disease.

Intensive Cardiac Rehabilitation (ICR) and CMS-Approved Programs

Section 1861(eee)(4) authorizes the Secretary to approve specific ICR programs that meet evidence-based intensity, multidisciplinary nature, and outcome documentation requirements. CMS approval is granted through a rulemaking process and requires the program to demonstrate superior outcomes compared to traditional CR.

Three ICR programs are currently approved:

1. The Pritikin Program

The Pritikin Program was approved by CMS in 2010 as the first ICR program. Based on the work of Nathan Pritikin and the Pritikin Longevity Center, the program uses an evidence-based plant-forward, low-fat dietary approach combined with supervised exercise, education, and behavioral modification. The Pritikin Program has been validated in multiple peer-reviewed studies showing favorable outcomes on lipid profile, blood pressure, glycemic control, and weight.

The Pritikin ICR Program is licensed to hospital systems that meet credentialing and operational requirements. Memorial Health University Medical Center in Savannah has been a notable Pritikin ICR provider in Georgia. Other Pritikin sites have come and gone in the state over the years.

2. Dr. Dean Ornish Program for Reversing Heart Disease

The Ornish Program was approved by CMS in 2010 as the second ICR program. Based on the work of Dr. Dean Ornish and the Preventive Medicine Research Institute, the program emphasizes a plant-based diet, supervised aerobic and strength exercise, stress management techniques including yoga and meditation, and group support. The Ornish Program has been validated in landmark studies including the Lifestyle Heart Trial, which demonstrated regression of coronary atherosclerosis under intensive lifestyle intervention.

Ornish Reversing Heart Disease Program availability in Georgia has been limited but has included select Piedmont and Wellstar sites at various times.

3. Benson-Henry Institute Cardiac Wellness Program

The Benson-Henry Institute Program was approved by CMS in 2014 as the third ICR program. Based on the work of Dr. Herbert Benson and the Benson-Henry Institute for Mind Body Medicine at Massachusetts General Hospital, the program emphasizes mind-body medicine including the relaxation response, stress reduction, supervised exercise, dietary counseling, and psychosocial support. The program is concentrated in Massachusetts and a small number of other markets, with very limited availability in Georgia.

BBA 2018 Section 51008: Non-Physician Practitioner Supervision

Section 51008 of the Bipartisan Budget Act of 2018 (Public Law 115-123), effective January 1, 2019, amended Section 1861(eee) to expand supervision authority for cardiac rehabilitation. Before January 1, 2019, only physicians could provide the direct supervision required for cardiac rehab. The BBA 2018 expansion added physician assistants (PAs), nurse practitioners (NPs), and clinical nurse specialists (CNSs) as authorized supervisors.

This expansion was driven by the recognition that physician supervision requirements were creating access barriers, particularly in rural areas of states like Georgia where physician availability is constrained. By allowing PAs, NPs, and CNSs to supervise CR, the statute increased the practical capacity of cardiac rehab programs.

For Georgia, the BBA 2018 expansion has been particularly valuable for cardiac rehab programs at rural hospitals and outlying locations of major health systems where physician supervision capacity is limited.

CAA 2024 Section 4117: ICR Program Approval Expansion

Section 4117 of the Consolidated Appropriations Act 2024 expanded the pathway for CMS approval of additional ICR programs. The provision established clearer criteria, reduced barriers, and created a more transparent process for evidence-based programs to seek ICR approval. The intent was to bring additional evidence-based programs into the ICR designation and improve geographic access to intensive cardiac rehabilitation.

As of 2026, no additional ICR programs have been approved under the CAA 2024 expanded pathway, but several programs are reportedly in various stages of preparation and submission.

Section 1862(a)(1)(A): Reasonable and Necessary

Section 1862(a)(1)(A) of the Social Security Act is the general "reasonable and necessary" coverage limitation. Cardiac rehabilitation services must be reasonable and necessary for the diagnosis or treatment of the qualifying cardiac condition. The medical record must document the qualifying condition, the medical necessity for cardiac rehab, and the individualized treatment plan.

Billing Codes and Payment Structure

Traditional Cardiac Rehabilitation Codes

• CPT 93797: Physician services for cardiac rehabilitation without continuous ECG monitoring (per session)
• CPT 93798: Physician services for cardiac rehabilitation with continuous ECG monitoring (per session)

When CR is delivered in a hospital outpatient department, the facility component is paid under OPPS:

• APC 5771 (Level 1 Cardiac Rehabilitation): National unadjusted payment approximately $110 per session for calendar year 2026
• APC 5772 (Level 2 Cardiac Rehabilitation): National unadjusted payment approximately $135 per session for calendar year 2026

The OPPS payment is wage-index adjusted for the hospital's geographic location.

Physician professional services are billed separately under MPFS using CPT 93797 or 93798 (or, for non-physician supervisors under BBA 2018 authority, the appropriate practitioner-specific billing).

Intensive Cardiac Rehabilitation Codes

• G0422: Intensive cardiac rehabilitation with continuous ECG monitoring, per session
• G0423: Intensive cardiac rehabilitation without continuous ECG monitoring, per session

ICR is paid at higher OPPS rates than traditional CR, reflecting the more intensive program design. The specific APC mapping for ICR codes is updated annually in the OPPS Final Rule.

Beneficiary Cost-Sharing

For both CR and ICR:

• Part B deductible: $257 in 2026 (applies to cardiac rehab and all other Part B services collectively)
• Coinsurance: 20 percent of the Medicare-approved amount after the deductible
• Per session out-of-pocket (before Medigap): approximately $22 to $27 for CR, approximately $25 to $35 for ICR
• Full 36-session course (traditional CR): approximately $800 to $1,000 total out-of-pocket before Medigap
• Full 72-session course (ICR or extended traditional CR): approximately $1,600 to $2,500 total before Medigap

Medigap supplemental insurance covers the 20 percent Part B coinsurance fully (under Plan G, grandfathered Plan F, and similar). Medigap Plan N covers the coinsurance subject to a copay of up to $20 per office visit, which can add up over a 36-session or 72-session program.

The Components of Cardiac Rehabilitation

A qualifying cardiac rehabilitation program delivers four components on each session day:

Physician-Prescribed Exercise

The exercise component is individualized based on the beneficiary's baseline exercise capacity, cardiovascular condition, comorbidities, and rehabilitation goals. Typical CR sessions include 30 to 45 minutes of supervised aerobic exercise on equipment such as treadmills, stationary bicycles, elliptical machines, and rowing ergometers. Strength training is increasingly incorporated. Exercise prescription specifies frequency, intensity, time, and type (the FITT principle).

Continuous ECG monitoring is provided during the early sessions and for higher-risk patients (post-AMI, post-CABG, heart failure, arrhythmia history). Lower-risk patients may transition to intermittent or no ECG monitoring as the program progresses.

Cardiac Risk Factor Modification

The risk factor modification component addresses smoking cessation, dietary modification, weight management, lipid control, blood pressure control, glycemic control in diabetic patients, medication adherence, and physical activity beyond the structured program. Education is delivered in individual and group formats. Behavioral intervention strategies include motivational interviewing, goal setting, action planning, and problem solving.

Psychosocial Assessment

The psychosocial assessment component identifies depression, anxiety, social isolation, low health literacy, financial stress, and other psychosocial factors that affect cardiac outcomes. Standardized screening tools such as the PHQ-9 (Patient Health Questionnaire-9) and GAD-7 (Generalized Anxiety Disorder-7) are commonly used. Identified psychosocial concerns are addressed through CR program resources or referral to appropriate clinicians.

Outcomes Assessment

The outcomes assessment component documents changes in exercise capacity (typically measured by MET level, 6-minute walk distance, or peak VO2), risk factor profile (lipid panel, blood pressure, weight, HbA1c, smoking status), and quality of life (Dartmouth COOP, SF-12, or condition-specific instruments). Outcomes data are used to track individual progress and to demonstrate program effectiveness.

Individualized Treatment Plan

The individualized treatment plan (ITP) integrates the four components into a structured rehabilitation curriculum. The plan must be reviewed by a physician every 30 days. The physician documentation must support the medical necessity of the program and any extensions beyond the standard 36 sessions for traditional CR.

Georgia Cardiac Rehabilitation Provider Landscape

Emory Healthcare

Emory Healthcare operates cardiac rehabilitation programs at multiple sites across the Atlanta metropolitan area, anchored by the Emory Heart and Vascular Center. Major Emory CR sites include Emory University Hospital, Emory Saint Joseph's Hospital, Emory University Hospital Midtown, Emory Decatur Hospital, Emory Johns Creek Hospital, and Emory Saint Joseph's Atlanta. Emory is one of the leading cardiac care programs in the Southeast and an academic medical center affiliated with Emory University School of Medicine.

Piedmont Healthcare

Piedmont Healthcare operates cardiac rehabilitation programs across its network of more than twenty hospitals. The Piedmont Heart Institute is one of the largest cardiac programs in Georgia. Cardiac rehab is available at Piedmont Atlanta Hospital, Piedmont Fayette Hospital, Piedmont Henry Hospital, Piedmont Newnan, Piedmont Mountainside, Piedmont Athens Regional, Piedmont Columbus Regional, Piedmont Augusta, Piedmont Macon Medical Center, and additional sites.

Wellstar Health System

Wellstar Health System operates cardiac rehabilitation programs through the Wellstar Heart and Vascular Institute at Wellstar Kennestone Regional Medical Center, Wellstar Cobb Hospital, Wellstar Douglas Hospital, Wellstar North Fulton, Wellstar Paulding, Wellstar Spalding Regional, Wellstar West Georgia, and other locations.

Northeast Georgia Health System

NGHS operates cardiac rehabilitation programs at Northeast Georgia Medical Center Gainesville and NGMC Braselton. The Heart Center of NGMC is a major regional cardiac program serving the rapidly growing North Georgia region.

Memorial Health (Savannah)

Memorial Health University Medical Center in Savannah operates cardiac rehabilitation programs including the Pritikin Intensive Cardiac Rehabilitation Program, one of the most prominent ICR programs in the Southeast. Memorial Health is a tertiary academic medical center serving coastal Georgia and the eastern part of the state.

AU Medical Center (Wellstar MCG Health)

Augusta University Medical Center, now operating as Wellstar MCG Health after the 2023 affiliation, operates cardiac rehabilitation as part of the Medical College of Georgia's cardiac care program. AU Medical Center serves the Central Savannah River Area.

Atrium Health Navicent

Atrium Health Navicent operates cardiac rehabilitation programs at the Medical Center Navicent Health in Macon and affiliated facilities, serving central Georgia.

Phoebe Putney Health System

Phoebe Putney Memorial Hospital in Albany operates cardiac rehabilitation programs serving southwest Georgia. The Phoebe Heart Institute is the major cardiac program for this region.

Grady Health System

Grady Memorial Hospital in Atlanta operates cardiac rehabilitation as part of its comprehensive cardiology program. Grady is the safety-net hospital for the metro Atlanta region and is affiliated with both Emory University School of Medicine and Morehouse School of Medicine.

Tanner Health System

Tanner Medical Center in Carrollton operates cardiac rehabilitation programs serving west Georgia.

Critical Access Hospitals and Rural Programs

Smaller rural hospitals and critical access hospitals across Georgia have variable cardiac rehabilitation availability. The BBA 2018 expansion of supervision authority to PAs, NPs, and CNSs has helped extend CR access into rural Georgia where physician supervision was previously a constraint.

Worked Example 1: Margaret, 78, Atlanta, Post-CABG Cardiac Rehabilitation at Piedmont Atlanta

Margaret is 78 years old, lives in Buckhead, has traditional Medicare with a Medigap Plan G supplement. Three weeks ago she presented to Piedmont Atlanta Hospital emergency department with crescendo unstable angina. Cardiac catheterization revealed three-vessel coronary disease, and she underwent triple coronary artery bypass graft (CABG) surgery. Her postoperative course was uncomplicated, and she was discharged on postoperative day six with a discharge plan including cardiac rehabilitation.

Margaret qualifies for cardiac rehabilitation under 42 CFR 410.49(b)(1) based on the CABG qualifying condition. Her cardiologist Dr. Williams refers her to the Piedmont Atlanta Cardiac Rehabilitation Program. The program intake includes a comprehensive evaluation by a registered nurse and exercise physiologist, baseline measurements (6-minute walk distance: 280 meters, equivalent to approximately 3.5 METs), risk factor assessment (mild hyperlipidemia, controlled hypertension, family history positive), and psychosocial assessment (PHQ-9 score 4, normal mood; GAD-7 score 3, normal anxiety).

Margaret enrolls in the program at three sessions per week, starting four weeks postoperative. Each session is 60 minutes including warm-up, supervised aerobic exercise on treadmill and stationary bicycle, strength training with light weights, cool-down, and weekly education topics (heart-healthy diet, medication management, smoking cessation, stress management, return to activity).

Each session is billed under OPPS APC 5771 (Level 1 Cardiac Rehabilitation) at approximately $110 wage-adjusted for Atlanta. Margaret has met her Part B deductible from earlier physician visits. She owes 20 percent coinsurance per session, approximately $22. Medigap Plan G covers the entire $22. Margaret's out-of-pocket per session: $0.

Margaret completes 36 sessions over 12 weeks (three sessions per week). Her 6-minute walk distance improves from 280 meters at baseline to 480 meters at completion (equivalent to approximately 6 METs). Her exercise capacity has nearly doubled. Her LDL cholesterol drops from 130 to 75 with adherence to her statin and dietary modification. Her blood pressure is well controlled. She has integrated daily walking into her routine and reports feeling "stronger and more confident than I have in years."

Margaret's total out-of-pocket cost for 36 sessions: $0. Her total Medigap premium for the year is approximately $2,000.

Worked Example 2: Robert, 82, Savannah, ICR Pritikin Program at Memorial Health Post-MI

Robert is 82, lives in Savannah, has traditional Medicare with no Medigap (he has a Humana Medicare Advantage HMO plan). Six weeks ago he had a non-ST elevation myocardial infarction (NSTEMI). Cardiac catheterization revealed a 90 percent stenosis in the left anterior descending artery, and he underwent percutaneous coronary intervention (PCI) with placement of a single drug-eluting stent. He was discharged on dual antiplatelet therapy, a high-intensity statin, beta-blocker, ACE inhibitor, and metformin (he has type 2 diabetes).

Robert's cardiologist recommends intensive cardiac rehabilitation rather than traditional CR due to his multiple risk factors (diabetes, hypertension, hyperlipidemia, family history, BMI 32) and the desire to optimize secondary prevention. Robert enrolls in the Memorial Health Pritikin Intensive Cardiac Rehabilitation Program.

The Pritikin program runs three sessions per day, three days per week, for eight weeks (72 sessions total). Each "session" is 60 minutes. The full program day at the ICR site includes supervised aerobic exercise (treadmill, bicycle, elliptical), strength training, education on the Pritikin dietary approach (plant-forward, low-fat, low-sodium, whole grains, generous fruits and vegetables), cooking demonstrations and tastings, stress management and relaxation training, and behavioral modification.

ICR is billed as HCPCS G0422 (with continuous ECG monitoring) at approximately $135 per session under OPPS, wage-adjusted for Savannah. Under Robert's Medicare Advantage plan, ICR is covered subject to a $20 copay per session. 72 sessions x $20 copay = $1,440 OOP. This falls below his MA plan's annual out-of-pocket maximum of $7,550.

Robert completes the 72-session Pritikin program. His outcomes are remarkable: weight drops 22 pounds (from 215 to 193), LDL cholesterol drops from 110 to 65, HbA1c improves from 7.8 to 6.4 on the same dose of metformin (he is able to discontinue his secondary diabetes medication), blood pressure improves from 145/85 to 122/76 on reduced medication, exercise capacity improves from 5 METs at baseline to 9 METs at completion. His estimated risk of repeat cardiac event over the next 10 years drops substantially based on the Reynolds Risk Score updated with his new measurements.

Worked Example 3: Linda, 75, Macon, Post-Valve Replacement at Atrium Health Navicent

Linda is 75 years old, lives in Macon, has traditional Medicare with a Medigap Plan G supplement. She was diagnosed with severe symptomatic aortic stenosis (peak gradient 65 mmHg, mean gradient 42 mmHg, valve area 0.7 cm²) two months ago. Two months ago she underwent surgical aortic valve replacement (SAVR) with a bioprosthetic valve at Atrium Health Navicent. Her surgical recovery has been uncomplicated.

Linda qualifies for cardiac rehabilitation under 42 CFR 410.49(b)(1) based on the "heart valve repair or replacement" qualifying condition. Her cardiac surgeon Dr. Park refers her to the Atrium Navicent Cardiac Rehabilitation Program. The program intake includes a comprehensive evaluation, baseline measurements (6-minute walk distance: 220 meters, equivalent to approximately 2.8 METs), risk factor assessment, and psychosocial evaluation.

Linda enrolls at three sessions per week, starting six weeks postoperative. Each session is billed under OPPS APC 5771 at approximately $110 wage-adjusted for Macon (Bibb County wage index ~0.85, so wage-adjusted payment approximately $98). Linda owes 20 percent coinsurance per session, approximately $20, covered fully by Medigap Plan G. OOP per session: $0.

Linda completes 36 sessions over 12 weeks. Her 6-minute walk distance improves from 220 meters at baseline to 410 meters at completion. Her exercise capacity nearly doubles. Her bioprosthetic valve is functioning well at follow-up echocardiography. She is cleared to return to all activities of daily living including driving, travel, and light yard work.

Linda's total out-of-pocket cost for 36 sessions: $0.

Worked Example 4: Charles, 80, Augusta, Heart Failure Cardiac Rehabilitation at AU Medical Center Post-2014 NCD Expansion

Charles is 80 years old, lives in Augusta, has traditional Medicare with a Medigap Plan G supplement. He has chronic systolic heart failure with reduced ejection fraction (HFrEF), with LVEF measured at 30 percent on the most recent echocardiogram. He has NYHA class III symptoms (marked limitation of physical activity, comfortable at rest, less than ordinary activity causes fatigue and shortness of breath). He is on optimal guideline-directed medical therapy including sacubitril-valsartan (Entresto), metoprolol succinate, spironolactone, and dapagliflozin. He has been on these medications for nine months without further uptitration possible.

Charles's cardiologist at AU Medical Center refers him for cardiac rehabilitation. He qualifies under 42 CFR 410.49(b)(1) based on the chronic heart failure qualifying condition added by NCD 20.10.1 in February 2014: LVEF at or below 35 percent, NYHA class II through IV, on optimal medical therapy for at least 6 weeks.

Counterfactual: before NCD 20.10.1 was issued in 2014, Charles would not have qualified for cardiac rehab under any of the original six qualifying conditions. He had no AMI, no CABG, no valve surgery, no PCI, no transplant, and his angina (if present) was not the primary clinical issue. He had advanced heart failure, period. The 2014 NCD made his cardiac rehab Medicare-covered.

Charles enrolls in the AU Medical Center Cardiac Rehabilitation Program at three sessions per week, with continuous ECG monitoring given his heart failure status. Each session is billed under OPPS APC 5772 (Level 2 Cardiac Rehabilitation, with monitoring) at approximately $135 wage-adjusted for the Augusta MSA. Charles owes 20 percent coinsurance per session, approximately $27, covered fully by Medigap Plan G. OOP per session: $0.

Charles completes 36 sessions over 12 weeks. His exercise capacity improves from 2.5 METs at baseline to 4 METs at completion. His NYHA functional class improves from III to II (slight limitation, comfortable at rest, ordinary activity causes some symptoms). His self-reported quality of life on the Kansas City Cardiomyopathy Questionnaire (KCCQ) improves substantially. He learns important self-management skills including daily weights, salt restriction, fluid management, and recognition of decompensation warning signs.

Worked Example 5: Patricia, 73, Columbus, Post-PCI Cardiac Rehab at Piedmont Columbus

Patricia is 73, lives in Columbus, has traditional Medicare with a Medigap Plan N supplement. Four weeks ago she had elective percutaneous coronary intervention (PCI) with placement of two drug-eluting stents at Piedmont Columbus Regional Midtown after positive nuclear stress test for stable angina pectoris. Her recovery has been uncomplicated. She is on dual antiplatelet therapy (aspirin plus clopidogrel for 12 months), a high-intensity statin, and a beta-blocker.

Patricia qualifies for cardiac rehabilitation under 42 CFR 410.49(b)(1) based on the PCI qualifying condition (which includes coronary stenting). Her cardiologist Dr. Anderson refers her to the Piedmont Columbus Cardiac Rehabilitation Program.

Patricia enrolls at three sessions per week. Each session is billed under OPPS APC 5771 at approximately $110 wage-adjusted for the Columbus MSA. Patricia owes 20 percent coinsurance per session, approximately $22.

Medigap Plan N covers the coinsurance subject to a $20 per visit copay (waived for ED visits not resulting in admission). Patricia's $22 coinsurance per session is largely covered by Medigap Plan N, but the $20 per visit copay applies. Patricia's OOP per session: $20.

36 sessions x $20 copay = $720 total OOP for the cardiac rehab program.

Counterfactual: had Patricia chosen Medigap Plan G instead of Plan N, her OOP for cardiac rehab would have been $0. Medigap Plan N's $20 per visit copay is the trade-off for Plan N's lower monthly premium (typically $30 to $50 per month less than Plan G). For Patricia, the lifetime premium savings of Plan N versus Plan G are substantial, but specific high-volume utilization events like a 36-session cardiac rehab course produce out-of-pocket exposure that Plan G would have eliminated.

Patricia completes 36 sessions. Her exercise capacity improves from 5 METs to 7.5 METs. Her stable angina symptoms have not recurred. She is cleared to return to her preferred activities including golf and gardening.

Worked Example 6: Henry, 85, Athens, Stable Angina with Atrial Fibrillation at Northeast Georgia Medical Center

Henry is 85 years old, lives in Athens, has traditional Medicare with a Medigap Plan G supplement. He has stable angina pectoris with coronary artery disease that is managed medically (no PCI or CABG has been indicated based on the extent and location of coronary lesions and the favorable response to medical therapy). He also has paroxysmal atrial fibrillation on apixaban (Eliquis) anticoagulation. He has hypertension and well-controlled type 2 diabetes.

Henry's cardiologist at Northeast Georgia Medical Center Athens refers him to cardiac rehabilitation. Henry qualifies under 42 CFR 410.49(b)(1) based on the "stable angina pectoris" qualifying condition.

Henry enrolls in the NGMC Athens Cardiac Rehabilitation Program at three sessions per week. The program supervises Henry with continuous ECG monitoring throughout his sessions given his atrial fibrillation history (to detect any arrhythmia during exercise). Each session billed under OPPS APC 5772 (Level 2, with monitoring) at approximately $135 wage-adjusted. Henry owes 20 percent coinsurance per session, approximately $27, covered fully by Medigap Plan G. OOP per session: $0.

Henry completes 36 sessions over 12 weeks. His exercise capacity improves modestly given his advanced age, from 3.5 METs at baseline to 5 METs at completion. His angina symptoms remain stable. His functional capacity improves enough that he can walk to his neighborhood mailbox and back without resting (which he could not do at baseline). His mood improves with social engagement at the program. He learns valuable self-management skills for his AFib including pulse self-monitoring and recognition of warning symptoms.

Fourteen Common Mistakes Georgia Beneficiaries and Families Make

Mistake 1: Not knowing cardiac rehabilitation is a Medicare benefit

Awareness is the largest barrier to cardiac rehabilitation participation. Many beneficiaries and even some physicians underestimate the strength of the evidence base and the breadth of Medicare coverage. If you have had any of the seven qualifying conditions, ask your cardiologist or primary care physician about cardiac rehabilitation.

Mistake 2: Confusing cardiac rehab with general physical therapy

Cardiac rehabilitation is a specialized cardiac-specific program with supervised exercise, education on cardiac risk factor modification, psychosocial assessment, and outcomes measurement, governed by Section 1861(eee) and 42 CFR 410.49. General outpatient physical therapy is governed by different regulations and uses different billing. The two are not interchangeable.

Mistake 3: Not asking about Intensive Cardiac Rehabilitation (ICR)

ICR programs (Pritikin, Ornish, Benson-Henry) provide 72 sessions over 18 weeks with evidence-based intensive curriculum compared to traditional CR's 36 sessions over 12 weeks. ICR availability is limited geographically, but where available it can be a powerful intervention. Memorial Health in Savannah has been a notable Pritikin ICR provider. Ask whether ICR is available in your area.

Mistake 4: Not knowing about heart failure cardiac rehab coverage

Heart failure became a qualifying condition for cardiac rehabilitation in February 2014 under National Coverage Determination 20.10.1. Beneficiaries with LVEF at or below 35 percent and NYHA class II through IV symptoms on optimal medical therapy for at least 6 weeks qualify. Many heart failure patients and even some clinicians are unaware of this coverage.

Mistake 5: Missing the 12-month myocardial infarction window

The acute myocardial infarction qualifying condition requires the AMI to be within the preceding 12 months at the time of cardiac rehab initiation. If you delay enrollment past 12 months and do not have another qualifying condition, you may not qualify. Initiate cardiac rehab as soon as your physician clears you, typically 2 to 6 weeks after the qualifying event.

Mistake 6: Not appealing a cardiac rehab denial

Cardiac rehabilitation denials, especially in Medicare Advantage, can usually be appealed successfully when the qualifying condition is clearly documented. Use the 5-level Medicare appeals process under Section 1869 of the Social Security Act.

Mistake 7: Stopping at 36 sessions when 72 may be approved

Under 42 CFR 410.49(g), traditional cardiac rehab can be extended from 36 to 72 sessions when medically necessary and documented by the physician. Don't stop at 36 sessions if your physician believes additional sessions would benefit you. The extended sessions are billed at the same rate.

Mistake 8: Not considering travel to access a Pritikin or Ornish ICR program

For motivated beneficiaries, traveling to a Pritikin ICR site (Memorial Health in Savannah is one of the most notable in the Southeast) or an Ornish ICR site can be transformative. The intensive 72-session curriculum produces measurable improvements in lipid profile, blood pressure, weight, glycemic control, and quality of life that traditional CR may not match.

Mistake 9: Not engaging with the risk factor modification education

Cardiac rehab programs include nutrition counseling, smoking cessation support, stress management, and medication adherence education. Beneficiaries who passively attend without engaging the educational components miss substantial benefit. The exercise is important, but the risk factor modification is what reduces long-term mortality.

Mistake 10: Assuming physician supervision is required

Since January 1, 2019, under Section 51008 of the Bipartisan Budget Act of 2018, physician assistants, nurse practitioners, and clinical nurse specialists can supervise cardiac rehabilitation. This expansion improves access especially in rural areas. Don't assume a program is unavailable just because the supervising physician is not always on site.

Mistake 11: Not asking about home-based or hybrid cardiac rehab

Some programs offer hybrid models with home-based or virtual components for some sessions. Telehealth-supported cardiac rehab is evolving. While the traditional model is in-person at a hospital outpatient facility, ask whether your program offers flexibility.

Mistake 12: Not utilizing the multidisciplinary team

Cardiac rehab programs include nurses, exercise physiologists, registered dietitians, sometimes social workers and pharmacists. These team members are valuable resources for questions about medication management, dietary changes, exercise progression, emotional adjustment, and return to work or other activities.

Mistake 13: Delaying program initiation too long after the qualifying event

Optimal cardiac rehab initiation is generally 2 to 6 weeks after the qualifying event (or earlier for some PCI and stable angina patients). Earlier initiation may be appropriate when clinically safe. Later initiation reduces some of the benefit. Don't wait six months or longer if you can start sooner.

Mistake 14: Not using cardiac rehab for prevention of repeat events

The primary clinical purpose of cardiac rehabilitation is secondary prevention: preventing future cardiac events, hospitalizations, and mortality. Engaging fully with all four CR components (exercise, risk factor modification, psychosocial assessment, outcomes measurement) produces measurable reductions in repeat events. Cardiac rehab is not just about recovery from the index event; it is about reducing risk for the next decade.

Frequently Asked Questions

::: accordion

What is cardiac rehabilitation?

Cardiac rehabilitation is a physician-supervised program that includes physician-prescribed exercise, cardiac risk factor modification (including education, counseling, and behavioral intervention), psychosocial assessment, and outcomes assessment. It is designed to improve cardiovascular health and reduce the risk of future cardiac events for beneficiaries with qualifying cardiac conditions.

What is the statutory basis for Medicare cardiac rehab coverage?

Section 1861(eee) of the Social Security Act, added by Section 144 of the Medicare Improvements and Extension Act of 2006 (Public Law 109-432). The implementing regulation is at 42 CFR 410.49.

Who qualifies for Medicare cardiac rehabilitation?

Under 42 CFR 410.49(b)(1), beneficiaries qualify if they have had one of seven conditions: (1) acute myocardial infarction within the preceding 12 months, (2) coronary artery bypass graft (CABG) surgery, (3) current stable angina pectoris, (4) heart valve repair or replacement, (5) percutaneous coronary intervention (PCI) including stent, (6) heart or heart-lung transplant, or (7) stable chronic heart failure with LVEF at or below 35 percent and NYHA class II-IV symptoms on optimal medical therapy for at least 6 weeks (added by NCD 20.10.1 in 2014).

How many sessions are covered?

Traditional cardiac rehabilitation: up to 36 one-hour sessions over 36 weeks, with extension up to 72 sessions when medically necessary and documented. Intensive cardiac rehabilitation (ICR): up to 72 one-hour sessions over 18 weeks.

What is the difference between CR and ICR?

Traditional cardiac rehabilitation (CR) is the standard program with 36 sessions over 12 to 18 weeks (typically 3 sessions per week). Intensive cardiac rehabilitation (ICR) is more intensive: 72 sessions over 18 weeks, delivered through CMS-approved programs with evidence-based intensive curriculum. ICR programs include the Pritikin Program, the Dr. Dean Ornish Program for Reversing Heart Disease, and the Benson-Henry Institute Cardiac Wellness Program.

Which ICR programs are approved by CMS?

Three: the Pritikin Program (approved 2010), the Dr. Dean Ornish Program for Reversing Heart Disease (approved 2010), and the Benson-Henry Institute Cardiac Wellness Program (approved 2014). Section 4117 of the Consolidated Appropriations Act 2024 expanded the pathway for additional ICR programs to seek approval.

Where can I get the Pritikin program in Georgia?

The Pritikin Intensive Cardiac Rehabilitation Program is available at Memorial Health University Medical Center in Savannah. Pritikin sites in other Georgia hospitals have come and gone over the years. Contact the program directly to verify current availability.

Where can I get the Ornish program in Georgia?

The Dr. Dean Ornish Program for Reversing Heart Disease has had limited availability in Georgia at select Piedmont and Wellstar sites at various times. Availability varies. Contact the program directly to verify current availability.

What does cardiac rehab cost?

The Part B deductible is $257 in 2026, and after the deductible, beneficiaries owe 20 percent coinsurance per session. Out-of-pocket per session is approximately $22 to $27 for CR and approximately $25 to $35 for ICR. Medigap Plan G or grandfathered Plan F covers the coinsurance fully. Medigap Plan N covers the coinsurance subject to a $20 per visit copay.

Are cardiac rehab programs covered by Medicare Advantage?

Yes. Medicare Advantage plans must cover all Medicare-covered services including cardiac rehabilitation. Cost-sharing structures vary by plan; many MA plans use flat copays per session.

What is included in a cardiac rehab session?

Each session is approximately 60 minutes and typically includes warm-up, supervised aerobic exercise (treadmill, stationary bicycle, elliptical, or rowing ergometer), strength training, cool-down, and educational content. Continuous ECG monitoring is provided during early sessions and for higher-risk patients.

Who supervises cardiac rehab?

Direct supervision is required and may be provided by physicians, physician assistants, nurse practitioners, or clinical nurse specialists. The expansion to PAs, NPs, and CNSs was enacted by Section 51008 of the Bipartisan Budget Act of 2018, effective January 1, 2019.

Can I do cardiac rehab in a physician's office?

Yes. Section 1861(eee) and 42 CFR 410.49 allow cardiac rehabilitation to be furnished in a physician's office or a hospital outpatient department. Office-based CR is paid under the Medicare Physician Fee Schedule.

Can I do home-based or virtual cardiac rehab?

Some programs offer hybrid models with home-based or virtual components for some sessions, particularly during and after the COVID-19 pandemic. Pure home-based or virtual cardiac rehabilitation is not yet broadly covered, but the landscape is evolving. Ask your local cardiac rehab program about their options.

How soon after my cardiac event should I start cardiac rehab?

Optimal initiation is generally 2 to 6 weeks after the qualifying event. For some elective PCI and stable angina patients, earlier initiation may be appropriate. Speak with your cardiologist about the optimal timing for your specific situation.

What is the evidence for cardiac rehab effectiveness?

Multiple large randomized controlled trials and meta-analyses demonstrate that cardiac rehabilitation reduces all-cause mortality by 13 to 26 percent, reduces cardiovascular mortality by 26 to 36 percent, reduces hospital readmissions, improves exercise capacity, improves quality of life, and improves medication adherence. The evidence base is one of the strongest in cardiovascular medicine.

Does cardiac rehab reduce my Medigap premium?

No, but it can reduce your overall Medicare and healthcare spending by reducing future hospitalizations and cardiac events. Participation in cardiac rehab is associated with lower readmission rates and lower repeat event rates.

What is the qualifying condition for cardiac rehab after heart failure?

Stable chronic heart failure with LVEF at or below 35 percent and NYHA class II through IV symptoms on optimal medical therapy for at least 6 weeks. Added by National Coverage Determination 20.10.1 in February 2014.

What is the qualifying condition for cardiac rehab after stable angina?

Current stable angina pectoris. Stable angina is anginal chest pain that has been stable in frequency, duration, and provoking factors over a defined period. Unstable angina becomes a qualifying condition after stabilization.

Can I extend cardiac rehab beyond 36 sessions?

Yes. Under 42 CFR 410.49(g), traditional cardiac rehab can be extended up to 72 sessions when medically necessary and documented by the physician. The MAC has discretion to approve extensions.

What is the 6-minute walk test?

The 6-minute walk test measures the distance a patient can walk on a flat surface in 6 minutes. It is a standard measure of exercise capacity used in cardiac rehab to assess baseline status and progress over the program. Improvements of 30 to 50 meters over a course of CR are common.

What is a MET?

A MET (metabolic equivalent of task) is a unit of energy expenditure. One MET represents resting metabolic rate. Light activity is roughly 2 to 3 METs (slow walking), moderate activity 3 to 6 METs (brisk walking, gardening), and vigorous activity 6+ METs (jogging, swimming). Cardiac rehab tracks improvements in MET capacity as a measure of exercise tolerance and fitness.

What is psychosocial assessment in cardiac rehab?

Psychosocial assessment identifies depression, anxiety, social isolation, and other psychosocial factors that affect cardiac outcomes. Tools such as the PHQ-9 (depression) and GAD-7 (anxiety) are commonly used. Identified concerns are addressed within the program or via referral.

Can I appeal a Medicare denial of cardiac rehab?

Yes. Under Section 1869 of the Social Security Act, beneficiaries have a 5-level appeals process: Level 1 redetermination, Level 2 reconsideration, Level 3 ALJ hearing, Level 4 Medicare Appeals Council, and Level 5 federal court. The redetermination is filed within 120 days of the initial determination.

Where do I find a cardiac rehab program in Georgia?

Search the AACVPR (American Association of Cardiovascular and Pulmonary Rehabilitation) program directory at aacvpr.org, contact your cardiologist for a referral, or call GeorgiaCares at 1-866-552-4464 for guidance. Major Georgia health systems including Emory, Piedmont, Wellstar, NGHS, Memorial Health, AU Medical Center, Atrium Health Navicent, and Phoebe Putney operate cardiac rehab programs.

:::

::: cta

Get Help With Georgia Medicare Cardiac Rehabilitation

If you have had a qualifying cardiac event and need help accessing cardiac rehabilitation, the resources below can help:

1. Medicare: 1-800-MEDICARE (1-800-633-4227)
2. Palmetto GBA (Jurisdiction J MAC): 1-877-567-9230
3. Kepro QIO (Quality of Care, Premature Discharge): 1-844-455-8708
4. GeorgiaCares SHIP (Free Counseling): 1-866-552-4464
5. DCH Medicaid Member Services: 1-866-211-0950
6. American Heart Association (AHA): 1-800-242-8721
7. AACVPR (Cardiac Rehab Provider Directory): 1-312-321-5146
8. Mended Hearts (Peer Support): 1-888-432-7899
9. Social Security Administration: 1-800-772-1213
10. HHS Office for Civil Rights: 1-800-368-1019
11. HHS Office of Inspector General Hotline: 1-800-447-8477
12. Medicare Rights Center: 1-800-333-4114
13. Center for Medicare Advocacy: 1-860-456-7790
14. Atlanta Legal Aid: 404-377-0701
15. Georgia Legal Services Program: 1-800-498-9469
16. 211 Georgia: Dial 2-1-1
17. Eldercare Locator: 1-800-677-1116
18. VA Benefits: 1-800-827-1000

For comprehensive eldercare guidance covering Medicare, Medicaid, VA benefits, caregiving, and senior heart health decisions, visit Brevy at brevy.com. The Brevy Care Team publishes state-specific deep dives covering every Medicare benefit category, every Medicaid pathway, and the on-the-ground provider landscape for families navigating eldercare in Georgia and across the country.

This guide is for informational purposes only and does not constitute legal, medical, or financial advice. Medicare rules change, and individual circumstances vary. Always verify current rules with Medicare, your Medicare Administrative Contractor (Palmetto GBA for Georgia), GeorgiaCares, your treating cardiologist, or a qualified professional before making decisions about cardiac rehabilitation or appeals.

:::